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SPECIAL REPORT
Acne and Nutrition: A Systematic Review
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Friederike FIEDLER1, Gabriele I. STANGL2, Eckhard FIEDLER1# and Klaus-Michael TAUBE1#
1
Department of Dermatology and Venereology, and 2Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-
Wittenberg, Halle (Saale), Germany
#
These authors contributed equally to this work.
Few well-defined, evidence-based nutritional recom-
mendations for people with skin diseases have been
Acta Dermato-Venereologica
publish­ed in the scientific literature and standard der-
matological textbooks. Using a systematic review of
acne vulgaris as an example, the aim of this study was
to determine whether there are systematic studies
on the topic and, if so, of what quality. Four eviden-
ce levels were defined: (A) double-blind randomized
study; (B) randomized study with serious limitations/
low number of cases; (C) case-control or cohort study;
and (D) expert opinion/case report. PubMed and Co-
chrane searches were performed using combinations
of the terms “diet”, “nutrition”, “meal” and “food”
with “acne”. Foodstuffs mentioned in relevant artic-
les were subdivided by evidence level and recorded as
having a beneficial (+), neutral (0) or adverse (–) ef-
fect. How­ever, only a small proportion of studies met
sufficiently high scientific standards that would enable
therapeutic recommendations to be made in practice.
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Key words: nutrition; acne; evidence level; overview.
Accepted Apr 28, 2016; Epub ahead of print May 3, 2016
Acta Derm Venereol 2017; 97: 7–9.
Corr: Friederike Fiedler, Department of Dermatology and Venereology, Mar-
tin Luther University Halle-Wittenberg, Ernst-Kromayer-Str. 5, DE-06112
Halle (Saale), Germany. E-mail: friederike.fiedler@halle-hautarzt.de
P atients often ask about the effects of nutrition on acne,
Advances in dermatology and venereology
but current research into this topic is very limited
compared with that of high-quality drug studies. One of
the main reasons for lack of research into nutrition and
acne is the high cost of appropriate studies, since, unlike
for medications, the expected efficacy is low and there
is a lack of options for increasing the price of foods to
finance research. Nonetheless, several nutritional studies
of various qualities have been published during the past
few decades. However, very few high-quality studies
meeting modern standards have been performed, and
those that have involve only a small proportion of the
wide range of foods available (1, 2). Some studies were
performed several years ago and, from today’s view-
point, have design flaws that would not allow dietary
recommendations to be made (3). The number of food
items that could be included in a meta-analysis is limited
because there is no, or not good enough, evidence about
many food items (1). An overview of all the foods that
This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta
Journal Compilation © 2017 Acta Dermato-Venereologica. ISSN 0001-5555
influence a specific disease, stratified by evidence level,
could support clinicians as well as researchers. Using a
systematic review of acne vulgaris as an example, the
aim of this study was to determine whether there are
systematic studies on the topic and, if so, of what quality.
METHODS
PubMed and Cochrane searches were performed with the search
terms “nutrition”, “diet”, “meal”, “food”, each in combination
with “acne”. The hits were then examined for relevant articles
using pre-defined criteria. Initially, the timeframe for the sample
search was limited to 11 years (Cochrane; 2004–2014) and 6 years
(PubMed; 2004–2009)1, respectively. Articles were classed as
relevant if foodstuffs, vitamins, trace elements, certain diets, food
forms, alcohol and nicotine were studied, or at least mentioned,
as influencing factors in the skin disease, and an effect was rated
beneficial/neutral/adverse. Furthermore, only studies of per os
administration in humans, but no studies of topical application,
cell culture or animal experiments were considered. All foods
with the respective effect reported were listed alphabetically in
a table and assessed by evidence level. The evidence level in the
Atkins and Bigby system (4, 5) was expanded to a search for
usually non-randomized studies by evidence Level D with expert
opinion or mention of the food. Otherwise, Level A corresponds
to randomized double-blind studies with a high number of cases,
Level B to randomized studies with serious limitations or a low
number of cases, and Level C to case-control or cohort studies.
Within each of the 4 evidence levels, adverse (–), neutral (0) or
beneficial (+) effects were differentiated into a corresponding total
of 12 groups. The results are summarized for each food as a row
in a table and illustrated by a graphical presentation with respect
to the results/evidence.
RESULTS
A total of 162/21 (PubMed/Cochrane) hits for acne were
found in the study timeframe, of which 58/6 relevant
articles on acne could be assessed based on the selec-
tion criteria (for a complete reference list in alphabetical
order, see Appendix S12). Higher grade studies (evidence
Levels A and B) were rarely found, while mentions of
foods (evidence Level D) formed a clear majority.
1
This study was part of FF’s medical doctoral thesis and thus has to reflect
its results. The addition of PubMed listed papers for a further 5 years
(2010–2014) would exceed the space limitations of the medical faculty
rules for medical doctor theses; thus, only the Cochrane database search
was expanded (2004–2014).
2
https://www.medicaljournals.se/acta/content/abstract/10.2340/00015555-2450
doi: 10.2340/00015555-2450
Acta Derm Venereol 2017; 97: 7–9
 8 F. Fiedler et al.

For acne there were 370 mentions of 146 influencing Table II. The 10 most-frequently studied/mentioned foods (and
smoking) in the examined time-frame
foods. Evidence assessment showed none of Level A, 4
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of Level B, 45 of Level C and 321 of Level D (Table I). Food

Total
Σ/–/0/+
Level A
–/0/+
Level B
–/0/+
Level C
–/0/+
Level D
–/0/+
While several foods were mentioned only once in Milk 22/17/5/0 0/0/0 0/0/0 2/0/0 15/5/0
connection with acne within the study timeframe, other Chocolate 17/7/10/0 0/0/0 0/0/0 2/0/0 6/10/0
foods or diets were mentioned up to 22 times within Milk products 17/13/3/1 0/0/0 0/0/0 0/1/0 13/2/1
Western diet 14/14/0/0 0/0/0 0/0/0 0/0/0 14/0/0
various evidence levels, sometimes with contradictory Low glycaemic load 12/0/0/12 0/0/0 0/0/2 0/0/1 0/0/9
influence (Table II). High glycaemic load 12/11/1/0 0/0/0 0/0/0 1/0/0 10/1/0
High glycaemic index 11/9/2/0 0/0/0 0/0/0 0/0/0 9/2/0
Low-fat milk 9/8/1/0 0/0/0 0/0/0 2/1/0 6/0/0
Smoking 7/1/4/2 0/0/0 0/0/0 0/2/0 1/2/2
DISCUSSION
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Pizza 6/1/5/0 0/0/0 0/0/0 0/2/0 1/3/0

There are polarizing, often speculative, opinions concer- For explanation of evidence levels see Table I and Methods.

ning the efficacy or non-efficacy of diets and foods as part

of the treatment of diseases, especially in dermatology.
This study systematically assessed the available scientific
literature with respect to the influence of food, using acne
as an example.
In comparison with drug testing, studies on the effect
of nutrition on skin diseases have rarely been performed
at evidence Levels A or B. High-quality studies are ex-
pensive and medication studies are usually amortized
with the selling price later on, which is not possible in
the case of foods. Randomizing and controlling human
subjects and diet is extremely difficult. There are many
confounders in nutrition studies, but less so in drug
studies. Double-blind testing is very difficult because
of the shape and the taste of the food. The best way to
test would be a double-blind placebo-controlled food
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As for other topics, the number of studies on individual
foods reveals a focus of scientific interest of often limited
timeframe. This, of course, limits the screened publica-
tion period, but, on the other hand, expanding the study
time period to 50 years or more would mean including a
number of older articles, which have serious limitations in
study structure (3, 6) according to today’s standards. This
expansion would be necessary to obtain the most complete
overview possible, but it is not appropriate in establishing
a prototype and in defining the analysis algorithm because
of the considerable effort and costs involved.
Multiple studies or mentions of a particular food in the
various evidence levels and with differing influence in a
text often limit the clarity of presentation of the result for
the reader. Thus, a graphical presentation is provided in

challenge (DBPCFC) including blinding of colour, shape
and taste, as used in food allergy testing, but this would
substantially increase overall expenditure.
In order to include the results of survey articles on
knowledge of foods, as well as those used as remedies
in natural medicines, and older articles cited currently
during the study period, the arrangement of evidence
levels as proposed by Atkins (4) and Bigby (5) was
Advances in dermatology and venereology
addition to the tabular presentation. This enables a visual
overview based on colour and distribution between right
and left over the study situation within the 12 possible
degrees of influence (evidence Levels A–D each with
3 categories: adverse/neutral/beneficial). Like a scale,
evidence Level A, with the highest quality, is always po-
sitioned at the edge comparable to the greatest leverage.
An identical distance right or left from the middle of

modified and expanded by a Level D for citations/expert
opinion/case reports. The results presented here, using
acne as an example, were selected because a connection
to nutrition is, or was, considered relatively certain by
both dermatologists and patients. In this respect, there are
a number of articles in the defined publication timeframe
that addressed the corresponding connections.
Only human studies were taken into account for the
assessment of relevance. In vitro studies were excluded in
order to limit our topic to practical relevance in nutrition.
Table I. Assessed foods mentions arranged by evidence levela
Level A Level B Level C Level D
Σ/–/0/+ Σ/–/0/+ Σ/–/0/+ Σ/–/0/+
Acne vulgaris 0/0/0/0 4/0/1/3 45/15/28/2 321/163/70/88
a
Level A corresponds to randomized double-blind studies with a high number of
cases, Level B to randomized studies with serious limitations or a low number
of cases, Level C to case-control or cohort studies, and Level D to usually non-
randomized studies expressing expert opinion or mention of the food. Within
each of the evidence levels, adverse (–), neutral (0) or beneficial (+) effects were
differentiated in a corresponding total of 12 groups. The results are summarized
for each item (bold figures).
the chart thus corresponds to the same evidence level,
but results with contradictory influence (left adverse
and right beneficial). The colours were borrowed from
a traffic light: red for adverse (–), yellow for neutral (0)
and green for beneficial (+) influence. Since graded as-
signment of the evidence level with neutral relationship
causes neither positive nor negative lateral shift in the
results, the neutral results were entered vertically in
yellow. Using milk in acne as an example (Fig. 1), an
adverse influence can be observed with entered numbers
only in the left horizontal arm. In this, many results were
near the centre of the chart at the lowest evidence, Level
D; but there are also 2 corresponding results at Level C.
Another 5 citations at Level D are shown in the lower
middle, which did not cause any shift between beneficial
and adverse.
For acne, 146 different foods were recorded a total
of 370 times in 60 relevant articles. There were only 49
studies with evidence Levels A–C. In these, none cor-
responded to evidence Level A, 4 cases corresponded to

www.medicaljournals.se/acta

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Fig. 1. Example: milk in acne. A total of 22 mentions include mostly
Acta Dermato-Venereologica
adverse effect (red/left horizontal arm), of these 2 at evidence Level C and
15 at Level D. Five articles reported no effect (Level D) (yellow/vertical
arm). No beneficial influence (green/right horizontal arm) of milk drinking
on acne was found.
Level B and 45 cases to Level C. The majority (86.7%)
corresponded to evidence Level D (assessed mention
without own study). The main impact of adverse food
effects relevant for the industrial countries in the lite-
rature studied was seen in the western diet, since the
introduction of this diet in populations whose traditional
nutrition had been different (7) resulted in a marked in-
crease in the incidence of acne. The main components
of the western diet are hyperglycaemic carbohydrates,
(cow’s) milk and saturated fats (8). The pathogenetic
effect of the western diet is mostly ascribed to the high
glycaemic load and high glycaemic index, hormonal
effects in cow’s milk and the shift in the omega-3-FA/
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omega-6-FA ratio in favour of omega-6-FA (7, 9, 10). The
adverse effect of milk and glycaemic load or glycaemic
index finds broad consensus (1, 2). The role of androgen
hormones in acne is well defined. Hyperinsulinaemia and
an increased insulin growth factor 1 (IGF-1) as a result
of high glycaemic load and dairy food intake cause an
increased production of androgen hormones and sebum
associated with acne (1, 2). Overactivated nutrient- and
growth factor sensitive kinase mechanistic target of ra-
Advances in dermatology and venereology
pamycin complex 1 (mTORC1) and downregulation of
nuclear transcription factor FoxO1 levels induced by a
western diet increase inflammation and comedogenesis
(8). High glycaemic load and hyperinsulinaemia decrease
insulin growth factor binding protein 3 (IGFBP-3), which
controls cellular growth (1). The resulting stimulation of
cellular growth leads to acne.
Some older studies (3) are repeatedly cited anecdotally
because of their methodological weaknesses. No well-
designed study has been performed to address the belief
still deep-rooted in the population that chocolate has an
adverse effect on acne.
There are fewer reports on the beneficial effects of
foods (n = 63, 17.0%) and adverse effects of avoidance
(n = 8, 2.2%) on acne than reports on foodstuffs with
Acne and nutrition 9
adverse effects when consumed (n = 165, 44.6 %) or
beneficial withdrawal (n = 28, 7.6%). Hence, it can be
concluded that acne is more likely.
CONCLUSION AND FUTURE WORK
The current system of collecting evidence on the effects
of nutrition on skin diseases could be improved. While
in modern drug testing many disruptive factors, such
as age, gender etc., are taken into account, confounders
caused by variation in the diets of study subjects are
usually not considered. However, in reviewing recent
scientific literature, there is evidence that foods can
influence skin diseases in various ways. In summary,
in the example of acne, according to the literature, milk
and foods with a high glycaemic burden are the best
candidates for food-triggered influence. However, it is
not currently possible to set out evidence-based nutritio-
nal recommendations in many cases (2). This database
linking various skin diseases with an alphabetical list of
foods may be help practitioners in making recommenda-
tions for dermatological patients concerning nutritional
guidance to support healing. Moreover, the results of
this collection may indicate suitable candidates for more
detailed testing, as long as the potential for beneficial
influence on the disease by the food is particularly high
or promising.
The authors declare no conflict of interest.
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